Hemorrhoidectomy: Does Age Make a Difference?

BACKGROUND: Grade II and III hemorrhoids often require a multimodal approach that may ultimately culminate in surgical resection. Age and overall medical conditioning around the time of diagnosis can often impact the decision. OBJECTIVE: The objective of this study was to evaluate patients with a diagnosis of symptomatic grade II or grade III hemorrhoids and determine progression to hemorrhoidectomy based on age and the time interval between diagnosis and surgical intervention. DESIGN: A retrospective cohort study. SETTINGS: Group practice at a single institution. PATIENTS: Patients aged 18 to 75 years with grade II or grade III internal hemorrhoids between 2015 and 2020 were included. Patients with thrombosed hemorrhoids or surgical contraindications to hemorrhoidectomy were excluded. A total of 961 patients met inclusion criteria for grade II (n = 442) and III (n = 519) hemorrhoids. INTERVENTION: Treatments included hemorrhoidectomy, in-office procedures, and/or medical management. MAIN OUTCOME MEASURES: Baseline demographics, treatment choices, and time to hemorrhoidectomy (if applicable) were stratified and analyzed on the basis of hemorrhoid grade (grade II and III) and age groupings that were predetermined by the authors (18-30, 31-50, and 51-75 years). RESULTS: Patients with grade III versus grade II hemorrhoids were more likely to choose hemorrhoidectomy as the initial treatment management (27.6% vs 4.1%). Patients in the age groups of 18 to 30 and 30 to 50 years were more likely to choose hemorrhoidectomy as the initial treatment management compared to those in the age group of 51 to 75 years (23.5% and 22% vs 12.8%). In patients who were initially treated with medical management or office-based procedures and then progressed to hemorrhoidectomy, no significant differences in the length of time to hemorrhoidectomy were noted on the basis of hemorrhoid grade or age. LIMITATIONS: Data only looked at age groups and their treatment selection. Personal biases of surgeon and patient may alter results. CONCLUSIONS: Our study shows that the younger population tends to seek hemorrhoidectomy first over the older population. See Video Abstract . HEMORROIDECTOMA LA EDAD MARCA LA DIFERENCIA: ANTECEDENTES:Las hemorroides de grado II y III a menudo requieren un abordaje multimodal que en última instancia puede culminar en una resección quirúrgica. La edad y el estado médico general en el momento del diagnóstico a menudo pueden afectar la decisión.OBJETIVO:El objetivo de este estudio fue evaluar a pacientes con diagnóstico de hemorroides sintomáticas grado II o grado III y determinar la progresión a hemorroidectomía en función de la edad y el intervalo de tiempo entre el diagnóstico y la intervención quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Práctica grupal en una sola institución.PACIENTES:Se incluyó a pacientes de 18 a 75 años con hemorroides internas de grado II o III entre 2015 y 2020. Se excluyeron los pacientes con hemorroides trombosadas o contraindicaciones quirúrgicas para hemorroidectomía. Un total de 961 pacientes cumplieron los criterios de inclusión para hemorroides de Grado II (n=442) y III (n=519).INTERVENCIÓN:Los tratamientos incluyeron hemorroidectomía, procedimientos en el consultorio y/o manejo médico.PRINCIPALES MEDIDAS DE RESULTADO:Los datos demográficos iniciales, las opciones de tratamiento y el tiempo hasta la hemorroidectomía (si corresponde) se estratificaron y analizaron según el grado de hemorroides (grado II y III) y los grupos de edad predeterminados por los autores (18-30, 31-50). y 51-75).RESULTADOS:Los pacientes con hemorroides de Grado III versus Grado II tuvieron más probabilidades de elegir la hemorroidectomía como tratamiento inicial (27,6% versus 4,1%). Los pacientes de los grupos de edad de 18 a 30 y de 30 a 50 años tenían más probabilidades de elegir la hemorroidectomía como tratamiento inicial en comparación con los de 51 a 75 años (23,5% y 22% frente a 12,8%). En los pacientes que inicialmente fueron tratados con manejo médico o procedimientos en el consultorio y luego progresaron a hemorroidectomía, no se observaron diferencias significativas en el tiempo hasta la hemorroidectomía según el grado o la edad de las hemorroides.LIMITACIONES:Los datos solo analizan los grupos de edad y su selección de tratamiento. Los sesgos personales del cirujano y del paciente pueden alterar los resultados.CONCLUSIÓN:Nuestro estudio muestra que la población más joven tiende a buscar primero la hemorroidectomía que la población de mayor edad. (Traducción-Dr. Felipe Bellolio ).

Identifying Bright Spot Counties for Appropriate Diabetes Preventive Care: A Geospatial, Positive Deviance Approach.

Positive deviance approaches, which have been used to identify and study high performers (bright spots) and translate their successes to poorer performers, offer great potential for chronic disease management. However, there are few examples of applying positive deviance approaches across different geographic contexts. Building on prior research that developed a new measure for appropriate diabetes preventive care (DMPrevCare) and identified priority counties for this strategy, we introduce a geospatial approach for identifying bright spot counties and case matching them to priority counties that need improvement. We used the Local Moran's I tool to identify DMPrevCare spatial outliers, which are counties with larger percentages of Medicare beneficiaries receiving appropriate diabetes preventive care (DMPrevCare) surrounded by counties with smaller percentages of Medicare beneficiaries receiving DMPrevCare. We define these spatial outliers as bright spots. The Robert Wood Johnson Foundation County Health Rankings Peer Counties tool was used to link bright spot counties to previously identified priority counties. We identified 25 bright spot counties throughout the southern and mountain western United States. Bright spot counties were linked to 45 priority counties, resulting in 23 peer (bright/priority) county groups. A geospatial approach was shown to be effective in identifying peer counties across the United States that had either poor or strong metrics related to DMPrevCare, but were otherwise similar in terms of demographics and socioeconomic characteristics. We describe a framework for the next steps in the positive deviance process, which identifies potential factors in bright spot counties that positively impact diabetes care and how they may be applied to their peer priority counties.

Sex Differences in Civilian Injury in Baghdad From 2003 to 2014: Results of a Randomized Household Cluster Survey.

OBJECTIVE: To examine sex differences in injury mechanisms, injury-related death, injury-related disability, and associated financial consequences in Baghdad since the 2003 invasion of Iraq to inform prevention initiatives, health policy, and relief planning. BACKGROUND: Reliable estimates of injury burden among civilians during conflict are lacking, particularly among vulnerable subpopulations, such as women. METHODS: A 2-stage, cluster randomized, community-based household survey was conducted in May 2014 to determine the civilian burden of injury in Baghdad since 2003. Households were surveyed regarding injury mechanisms, healthcare required, disability, deaths, connection to conflict, and resultant financial hardship. RESULTS: We surveyed 900 households (5148 individuals), reporting 553 injuries, 162 (29%) of which were injuries among women. The mean age of injury was higher among women compared with men (34 ±â€Š21.3 vs 27 ±â€Š16.5 years; P < 0.001). More women than men were injured while in the home [104 (64%) vs 82 (21%); P < 0.001]. Fewer women than men died from injuries [11 (6.8%) vs 77 (20%); P < 0.001]; however, women were more likely than men to live with reduced function [101 (63%) vs 192 (49%); P = 0.005]. Of intentional injuries, women had higher rates of injury by shell fragments (41% vs 26%); more men were injured by gunshots [76 (41%) vs 6 (17.6%); P = .011). CONCLUSIONS: Women experienced fewer injuries than men in postinvasion Baghdad, but were more likely to suffer disability after injury. Efforts to improve conditions for injured women should focus on mitigating financial and provisional hardships, providing counseling services, and ensuring access to rehabilitation services.

Exploring Health Beliefs Among Hispanic Adults with Prediabetes.

Diabetes and prediabetes are increasing in prevalence, corresponding to epidemic rates of obesity. Hispanic adults with prediabetes are 1.7 times more likely than non-Hispanic whites to progress to diabetes. We set out to understand health beliefs of Hispanic adults and, with that knowledge, facilitate tailored messaging to promote patient activation and lifestyle change. Using the Risk Perception Survey for Developing Diabetes along with demographic and lifestyle intervention interest questions, a 34-question survey was mailed to a registry of Hispanic adults with a diagnosis of prediabetes and an HbA1c between 5.7 and 6.4% (N = 414). Despite more than three-quarters of respondents (n = 92; 77%) indicating they had prior knowledge of their diagnosis, overall diabetes risk knowledge was low. A significant difference in diabetes risk knowledge was found between groups stratified by education level. High scores in personal control and worry were reported. Respondents overwhelmingly reported interest in exercise (n = 92; 77%) and healthy eating interventions (n = 60; 50%) over technology-based interventions. High levels of worry and personal control, combined with low to intermediate levels of risk knowledge, indicate an opportunity for education and activation in this community. Healthy eating and exercise programs are possible interventions that may slow the progression from prediabetes to diabetes.

Qualitative Exploration of Geospatially Identified Bright Spots and Priority Areas to Improve Diabetes Management.

BACKGROUND: Type 2 diabetes (T2DM) results in significant morbidity and mortality and is associated with disparities in prevalence, treatment, and outcomes. GIS can identify geographically based disparities. In the focused Rapid Assessment Process (fRAP)-a novel mixed-method study design-GIS is combined with qualitative inquiry to inform practice interventions and policy changes. METHODS: Using fRAP, areas with poor T2DM outcomes (priority areas) as well as areas with positive T2DM outcomes (bright spots) were identified, focus groups were conducted, and responses analyzed for intervention opportunities. Focus group participants were English- and Spanish-speaking patients with T2DM living in one of the identified areas. Qualitative analysis consisted of initial coding with a priori themes from the focus group question guide, followed by identification of emergent themes within each defined category. RESULTS: The a priori categories included Facilitators, Barriers, Strategies, and Impact of Diabetes Diagnosis. Emerging recurrent themes were Interactions with Medical Professionals, Medications, Lifestyle Management, Family Motivators and Support, Self-Efficacy, and Social Needs and Community Resources. CONCLUSIONS: Thematic results from focus groups can be used by practices to improve T2DM care through educating patients about chronic disease and nutrition, connecting them to diabetes-specific services, learning how diabetes fits in the context of patient lives, and eliciting patient values and motivations to improve diabetes self-management. Findings also may be used by health care professionals to inform community-based advocacy efforts, interventions, and future research.

Identifying priority and bright spot areas for improving diabetes care: a geospatial approach.

The objective of this study was to describe a novel geospatial methodology for identifying poor-performing (priority) and well-performing (bright spot) communities with respect to diabetes management at the ZIP Code Tabulation Area (ZCTA) level. This research was the first phase of a mixed-methods approach known as the focused rapid assessment process (fRAP). Using data from the Lehigh Valley Health Network in eastern Pennsylvania, geographical information systems mapping and spatial analyses were performed to identify diabetes prevalence and A1c control spatial clusters and outliers. We used a spatial empirical Bayes approach to adjust diabetes-related measures, mapped outliers and used the Local Moran's I to identify spatial clusters and outliers. Patients with diabetes were identified from the Lehigh Valley Practice and Community-Based Research Network (LVPBRN), which comprised primary care practices that included a hospital-owned practice, a regional practice association, independent small groups, clinics, solo practitioners and federally qualified health centres. Using this novel approach, we identified five priority ZCTAs and three bright spot ZCTAs in LVPBRN. Three of the priority ZCTAs were located in the urban core of Lehigh Valley and have large Hispanic populations. The other two bright spot ZCTAs have fewer patients and were located in rural areas. As the first phase of fRAP, this method of identifying high-performing and low-performing areas offers potential to mitigate health disparities related to diabetes through targeted exploration of local factors contributing to diabetes management. This novel approach to identification of populations with diabetes performing well or poor at the local community level may allow practitioners to target focused qualitative assessments where the most can be learnt to improve diabetic management of the community.

Factors Associated with Clinician Adherence to USPSTF Diabetes Screening Recommendations.

INTRODUCTION/OBJECTIVES: Diabetes and prediabetes impact nearly half of the US adult population and are associated with significant health risks but may be underdiagnosed. Effective screening may improve diagnosis and give patients opportunity to manage their disease. The purpose of this study was to determine screening rates, identify characteristics predictive of screening, and evaluate correct diagnosis of diabetes and prediabetes. METHODS: Retrospective chart review of 71 433 patients eligible for diabetes screening, defined by completing A1c test within the 3-year study period. RESULTS: A total of 31.3% of eligible patients received diabetes screening. Factors associated with screening include older age, female sex, non-white race, Hispanic ethnicity, Medicare or Medicaid insurance, higher BMI, and having a medical comorbidity. History of prediabetes or gestational diabetes were the strongest predictors for diabetes screening, but history of gestational diabetes was under-documented. Of those screened, 10.4% had a result consistent with diabetes and 51.8% had a result consistent with prediabetes. However, 52.9% of these patients had a missed diagnosis. CONCLUSIONS: Findings of this study indicate the need for uniform coverage for diabetes screening for all insurances, increased documentation of gestational diabetes to improve screening for patients with this history, and improving accurate diagnosis after screening is completed.

Key Factors Promoting Rapid Implementation of Virtual Screening Modalities for the COVID-19 Pandemic Response.

BACKGROUND: The COVID-19 (C-19) pandemic required swift response from health care organizations to mitigate spread and impact. A large integrated health network rapidly deployed and operationalized multiple access channels to the community, allowing assessment and triage to occur virtually. These channels were characterized by swift implementation of virtual models, including asynchronous e-visits and video visits for C-19 screening. PURPOSE: (1) Evaluate implementation characteristics of C-19 screening e-visits and video visits. (2) Identify volume of C-19 screening and other care provided via e-visits and video visits. (3) Discuss future implications of expanded virtual access models. METHODS: Retrospective analysis of implementation data for C-19 screening e-visits and video visits, including operational characteristics and visit/screening volumes conducted. RESULTS: Virtual channels were implemented and rapidly expanded during the first week C-19 testing was made available. During the study period, primary care clinicians conducted 10,673 e-visits and 31,226 video visits with 9,126 and 26,009 patients, respectively. Within these 2 virtual modalities, 4,267 C-19 tests were ordered (10% of visits). Four hundred forty-eight clinicians supported 24/7 access to these virtual modalities. DISCUSSION: Given ongoing patient interest and opportunity, virtual health care services will continue to be available for an expanded number of symptoms and diagnoses.

Identifying diabetes management opportunity areas in the USA.

Using adherence to diabetes management guidelines as a case study, this paper applied a novel geospatial hot-spot and cold-spot methodology to identify priority counties to target interventions. Data for this study were obtained from the Dartmouth Atlas of Healthcare, the United States Census Bureau's American Community Survey and the University of Wisconsin County Health Rankings. A geospatial approach was used to identify four tiers of priority counties for diabetes preventive and management services: diabetes management cold-spots, clusters of counties with low rates of adherence to diabetes preventive and management services (Tier D); Medicare spending hot-spots, clusters of counties with high rates of spending and were diabetes management cold-spots (Tier C); preventable hospitalisation hot-spots, clusters of counties with high rates of spending and are diabetes management cold-spots (Tier B); and counties that were located in a diabetes management cold-spot cluster, preventable hospitalisation hot-spot cluster and Medicare spending hot-spot cluster (Tier A). The four tiers of priority counties were geographically concentrated in Texas and Oklahoma, the Southeast and central Appalachia. Of these tiers, there were 62 Tier A counties. Rates of preventable hospitalisations and Medicare spending were higher in Tier A counties compared with national averages. These same counties had much lower rates of adherence to diabetes preventive and management services. The novel geospatial mapping approach used in this study may allow practitioners and policy makers to target interventions in areas that have the highest need. Further refinement of this approach is necessary before making policy recommendations.

Designing and Evaluating a Prediabetes Shared Decision Aid.

BACKGROUND: Prediabetes is increasing in prevalence and is associated with risk of developing diabetes, heart disease, stroke, and retinopathy. Clinicians have limited tools to facilitate prediabetes discussions within primary care visits. PURPOSE: 1) Develop a Patient and Stakeholder Advisory Committee (PASAC) to design, evaluate, and revise a prediabetes shared decision aid, and 2) evaluate the feasibility and experience of implementing the tool within primary care practice. METHODS: A prediabetes decision aid (double-sided infographic with decision questions) was created by a PASAC that included patients, primary care clinicians, diabetes educators, endocrinologists, and pharmacists. Five clinicians within 3 primary care practices tested the prediabetes tool with 50 adult patients with prediabetes. Patients completed 2 surveys immediately after the office visit and 6 weeks later. Clinicians and PASAC members completed a postintervention survey. RESULTS: The prediabetes shared decision aid was created through a deliberative process over 3 PASAC meetings. Ninety-six percent of patients felt the tool prepared them to decide on a diabetes prevention plan, and 100% of clinicians would use the tool again and felt the tool did not extend visit length. DISCUSSION: It was feasible to cocreate a prediabetes shared decision aid within a PASAC and implement the tool within a primary care setting. Patients and clinicians reported a prediabetes discussion, which may mitigate rates of progression to diabetes and associated complications. Future research should evaluate which of the intervention components most effectively promotes discussion of prediabetes within a primary care setting.

Decision Support and Navigation to Increase Colorectal Cancer Screening Among Hispanic Patients.

BACKGROUND: Effective strategies are needed to raise colorectal cancer screening rates among Hispanics. METHODS: We surveyed and randomized 400 Hispanic primary care patients either to a Decision Support and Navigation Intervention (DSNI) Group (n = 197) or a Standard Intervention (SI) Group (n = 203). Both groups received a colorectal cancer screening kit [bilingual informational booklet, fecal immunochemical stool blood test (SBT), and colonoscopy screening instructions]. The DSNI Group received a telephone contact from a patient navigator. The navigator clarified screening test preference and likelihood of test performance, helped to develop a screening plan, and provided guidance through test performance. An endpoint telephone survey and medical chart review were completed. Multivariable analyses were conducted to assess 12-month screening adherence, change in decision stage, and knowledge and perceptions. RESULTS: Screening adherence was significantly higher in the DSNI Group than the SI Group [OR, 4.8; 95% confidence interval (CI), 3.1-7.6]. The DSNI Group, compared with the SI Group, also displayed higher SBT screening [OR, 4.2; 95% CI, 2.6-6.7), higher colonoscopy screening (OR, 8.8; 95% CI, 4.1-18.7), and greater forward change in screening decision stage (OR, 4.9; 95% CI, 2.6-9.5). At endpoint, study groups did not differ in screening knowledge or perceptions. CONCLUSIONS: The DSNI had a greater positive impact on colorectal cancer screening outcomes than the SI. IMPACT: Health system implementation of DSNI strategies may help to reduce Hispanic colorectal cancer screening disparities in primary care.

Clinician-Reported Barriers to Group Visit Implementation.

BACKGROUND: Group visits have been shown to improve disease-oriented outcomes and satisfaction, yet many clinicians have not incorporated them into practice. We aimed to identify clinician-reported barriers that preclude clinicians from implementing group visits. METHODS: Primary care physicians from one practice-based research network were surveyed regarding their experience with and barriers to group visits. The survey, developed for this study, was mailed to 246 clinicians. RESULTS: Of 107 respondents (44% response rate), those in practice <10 years were significantly more likely to have had group visit experience than those with >10 years of experience. For those without prior group visit experience, training was named as the top barrier to incorporating group visits. Those with group visit experience named staffing concerns and recruitment as the top barriers to group visit implementation. CONCLUSIONS: Primary care clinicians without prior group visit experience were less likely to endorse group visits. Addressing the modifiable barriers may enhance the incorporation of group visits into practice.

Implementation of Technology-based Patient Engagement Strategies within Practice-based Research Networks.

BACKGROUND: Technology-based patient engagement strategies (such as patient portals) are increasingly available, yet little is known about current use and barriers within practice-based research networks (PBRNs). PBRN directors have unique opportunities to inform the implementation of patient-facing technology and to translate these findings into practice. METHODS: PBRN directors were queried regarding technology-based patient engagement strategies as part of the 2015 CAFM Educational Research Alliance (CERA) survey of PBRN directors. A total of 102 PBRN directors were identified via the Agency for Healthcare Research and Quality's registry; 54 of 96 eligible PBRN directors completed the survey, for a response rate of 56%. RESULTS: Use of technology-based patient engagement strategies within PBRNs was limited, with less than half of respondents reporting experience with the most frequently named tools (risk assessments/decision aids). Information technology (IT) support was the top barrier, followed by low rates of portal enrollment. For engaging participant practices, workload and practice leadership were cited as most important, with fewer respondents noting concerns about patient privacy. DISCUSSION: Given limited use of patient-facing technologies, PBRNs have an opportunity to clarify the optimal use of these strategies. Providing IT support and addressing clinician concerns regarding workload may facilitate the inclusion of innovative technologies in PBRNs.

Patient-Reported Barriers and Limitations to Attending Diabetes Group Visits.

PURPOSE: Through this exploratory study, we sought to understand why group visit participation is low among adult patients with type 2 diabetes. METHODS: Eligible study participants included adult patients with type 2 diabetes. After a pilot survey was sent to a random sample of 48 patients, the remaining 187 eligible patients were invited to complete a revised version of the survey. RESULTS: Most frequently cited reasons for not attending group visits included diabetes under control, work and/or other responsibilities, and time barriers. There was variability in the desired time for the visits, though the majority of patients preferred evening visits. While some patients reported copays as a challenge, the likelihood of attending did not decrease for this subgroup. Most patients surveyed (54%) indicated interest in diabetes group visits. CONCLUSION: Implementing strategies to address the patient-identified system barriers (eg, time, transportation, and copays) may increase participation in diabetes group visits.